Every finding on record at Oak Hammock at the University of Florida Inc

Based on observation, interview, and record review, the facility failed to obtain the medication dosage prior to administration for 1 of 3 residents reviewed for pain management (Resident #86).Findings include:During an observation on 6/29/2026 at 12:16 PM, Resident #86 was sitting upright in the bed with family members at the bedside. The resident was rubbing her left leg, grimacing. During an interview on 6/29/2026 at 12:16 PM, Resident #86 stated, My leg hurts all over sometimes on the top, then the pain moves to the side. Right now, it's hurting right here [points to inner calf left leg]. I want my oxycodone on time. If they bring it late, then my pain gets really bad.Review of Resident #86's physician order dated 6/23/2026 read, Diclofenac Sodium External Gel 1% (Diclofenac Sodium (Topical)). Apply to painful areas to LLE [Left Lower Extremity] topically four times a day for pain. The required dosage for application was not documented.Review of Resident #86's Medication Administration Record for June 2026 for application of diclofenac sodium topical gel showed the resident received the medication from 6/23/2026 through 6/30/2026 at 9 AM, 1:00 PM, 5:00 PM, and 9:00 PM.During an interview on 6/30/2026 at 1:07 PM, Staff A, Licensed Practical Nurse (LPN), stated, Normal dose for Voltaren [Diclofenac Sodium external gel 1%] is 2-4 grams and the dosage should be written.During an interview on 6/30/2026 at 1:30 PM, the Director of Nursing verified there was no dosage written for Voltaren and should be included in physician orders.Review of the facility policy and procedure titled Medication Administration with the last review date of 12/2/2025 read, Policy: It is the policy of the facility to ensure that medications that are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician, and is done in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on observation, interview, and record review, the facility failed to ensure food items were stored according to professional standard of practice, failed to serve foods at safe temperatures, and failed to ensure staff prepared food in accordance with professional standards to prevent the possible spread of food borne illness. (Photographic evidence obtained). Findings include: During an observation on 3/10/2025 at 9:15 AM with the Culinary Services Manager in the Main Dining Room, there were two packages of a food item that were not in the original packaging in the freezer with no identifying label. In refrigerator 1 there was a bag containing a white liquid with no identifying label or date. During an interview on 3/10/2025 at 9:19 AM, the Culinary Service Manager identified the food item in the bag stored in the refrigerator as yogurt and the two packages in the freezer as food molds of purred beef. The Culinary Service Manager stated, The food items should be labeled and/or dated in the refrigerator and freezer. During an observation on 3/11/2025 at 11:50 AM, there was one opened pack of unsalted butter and two packs of ready-to eat turkey sandwiches not in the original packaging that were not labeled with an open date. During an interview on 3/11/2025 at 11:58 AM, the Morning [NAME] stated the butter and turkey sandwiches needed to be labeled. During an observation on 3/11/2025 starting at 12:05 PM of the Culinary Service Manager, and the Morning Cook, the Morning [NAME] took the temperature of the prepared gravy. The Morning [NAME] did not sanitize the temperature probe with an alcohol wipe after tempting the gravy and put the thermometer probe into the prepared tuna salad and took the temperature of the tuna salad. During an observation of the lunch meal distribution service on 3/11/2025 at 12:10 PM with the Culinary Service Manager, the Morning [NAME] placed a piece of salmon on a plate and moved the salmon to the center of the plate with his gloved right hand. The Morning [NAME] did not remove his glove, did not perform hand hygiene and opened the microwave oven door with his gloved right hand to remove a heated food item. The Morning [NAME] did not remove his glove, did not perform hand hygiene, returned to the steam table. The Morning [NAME] placed noodles on a plate and pushed the noodles to the center of the plate with his gloved right hand. The Morning [NAME] did not remove the glove, did not perform hand hygiene and removed beef tips out of a container that was on the steamtable with a ladle and placed the beef tips directly on the steamtable, without a barrier, and started cutting them. During an interview on 3/11/2025 at approximately 12:10 PM the Culinary Service Manager was interviewed regarding the observations. The Culinary Service Manager instructed the Morning [NAME] to throw away the beef tips. The Morning [NAME] did not remove his glove, did not perform hand hygiene, picked up a plate, scraped the beef tips with his gloved right hand unto the plate, and disposed of the beef tips by throwing them away in the trash can. The Morning [NAME] did not remove his glove, did perform hand hygiene, and went back to the steam table to continue serving the food. During an interview on 3/11/2025 at approximately 12:10 PM, the Culinary Service Manager, who was present at the time of observations, confirmed the findings and stated that touching food items with gloved hands is not our practice and the Morning [NAME] should have changed the gloves after using the microwave oven and after throwing away the beef tips. Review of the facility policy and procedure titled Date labeling for Food Safety reviewed in January 2025 read, Policy The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food . Policy Explanation and Compliance Guidelines for Staffing . 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. Review of the facility policy and procedure titled Food Safety Requirements reviewed in January 2025 read, Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Definitions . Food Distribution means the process involved in getting food to the resident. This may include holding foods hot on the steam table or under refrigeration for cold temperature control, dispensing food portions for individual residents, family style and dining room service or delivering meals to residents' rooms or dining areas, etc . Policy Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident . 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. A. Staff shall wash hands according to facility procedures. b. Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas . 8. Additional strategies to prevent foodborne illness include, but are not limited to: a. Preventing cross-contamination of foods.

Based on record review and interview the facility failed to provide Advance Beneficiary notice of non-coverage in a timely manner for 2 of 3 residents reviewed for beneficiary notification, Resident #36 and #172. Findings include: Review of Resident #36's Notice of Medicare non-coverage showed Medicare coverage of current skilled nursing services would end on 3/01/2025. Review of Resident #36's Advance Beneficiary Notice of Non-coverage (ABN) was signed by Resident #36 on 3/07/2025. Review of Resident #172's Notice of Medicare non-coverage showed Medicare coverage of current skilled nursing services would end on 12/24/2024 Review of Resident #172's Advance Beneficiary Notice of Non-coverage (ABN) was signed by Resident #36 on 12/30/2024. During an interview on 03/12/2025 at 10:15 AM with the Quality Improvement Manager stated, [Resident #36's name] Advanced Beneficiary Notice of Non-Coverage (ABN) should have been given before 3/1/2025 which was her last cover day for Part A services. [Resident #36's name] ABN was given on 3/7/2025. [Resident #172's name] ABN was given on 12/30/2024 passed the last cover day of her Part A services of 12/24/2024. [Resident #172's name] ABN should have been given before that date. An ABN should be given two calendar days before the last day of coverage. Review of the policy and procedure titled Advanced Beneficiary Notice (ABN) and Notice of Non-Coverage (NOMNC) with a last review date of 12/16/2024 read, Policy: It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage.

Based on record review and interview, the facility failed to obtain laboratory services to meet the needs for 1 of 5 residents reviewed for medication administration, Resident #41. Findings include: Review of Resident #41's physician order dated 6/20/2024 read, Check BMP [basic metabolic panel] every other week. Review of Resident #41's laboratory results for BMP showed a BMP was drawn on 2/4/2025 and 3/6/2025. Review of Resident #41's Treatment Administration Record (TAR) for February 2025 did not contain documentation of a BMP being drawn on 2/19/2025 as ordered by the physician. During an interview on 3/13/2025 at 9:37 AM, the DON (Director of Nursing) stated, I reviewed the resident's chart, and the BMP was not drawn according to the physician order. During an interview with on 3/12/2025 at 11:09 AM, the Medical Doctor #1 stated that her expectations would be that if she ordered a lab to be drawn every other week, the facility would draw the lab as ordered. Record review of the facility's policy titled, Laboratory Services last reviewed on 12/16/2024, stated: Policy: The facility must provide or obtain laboratory services to meet the needs of its residents and is responsible for the quality and timeliness of the services.

Based on record review and interview, the facility failed to ensure accuracy of minimum data set assessments for 2 of 5 residents, Residents #9 and #46. Findings include: 1) Review of Resident #9's physician order with a start date of 8/30/2024 read, Risperidone oral tablet 0.5 mg give 1 tablet by mouth one time a day for bipolar disorder. Review of Resident #9's Minimum Data Set (MDS) titled Quarterly dated 12/8/2024 read, Section N Medication: Antipsychotic: No. Review of Resident #9's Medication Administration Record (MAR) for the month of December 2024 documented the administration of Risperidone oral tablet daily. During an interview on 3/12/2025 at 12:48 PM with the MDS Coordinator stated, [Resident #9's name] Section N has a data entry error he was on antipsychotic medication. During an interview on 3/12/2025 at 12:58 AM with the Director of Nursing (DON) stated, We follow the Resident Assessment Instrument (RAI) manual. 50123 2) Review of Resident #46's physician order dated 2/13/2025 read, Quetiapine Fumarate oral tablet 400 mg. Give 1 tablet by mouth one time a day for severe depression refractory with psych features. Review of Resident #46's MAR for February 2025 documented the resident was administered Quetiapine Fumarate starting on 2/13/2025, which is prior to the initiation of the Admission/5-Day Minimum Data Set (MDS) assessment. Review of Resident #46's Admission MDS dated [DATE] did not document the resident was receiving antipsychotic medication under Section N0415, High Risk Drug Classes. During an interview on 3/12/2025 at 12:30 PM, the MDS Coordinator stated, It was obviously a data entry error. During an interview on 3/12/2025 at 12:30 PM, the MDS Coordinator related that there was no facility policy for Minimum Data Set completion. We use the RAI [Resident Assessment Instrument]. 3) Review of Resident #14's Admission Minimum Data Set (MDS) dated [DATE] documented the resident had adequate hearing without hearing devices under Section B. Sensory. Review of Resident #14's care plan 12/22/2024 documented a focus for the resident being hard of hearing and requiring a right hearing aid. During an interview on 3/12/2025 at 12:30 PM, the MDS Coordinator stated, I guess he wasn't wearing it when I did his MDS.

Based on observation, interview, and record review the facility failed to follow infection control standards for following enhanced barrier precautions to prevent the possible spread of infection for 1 of 3 residents for enteral nutrition, Resident #57. Findings include: During an observation 3/10/2024 at 10:24 AM, Staff B, License Practical Nurse (LPN), entered Resident #57's room without donning a gown. Resident #57's room door has an enhanced barrier sign posted outside of the room. Staff B performed hand hygiene and don gloves but did not don a gown. Staff B stopped Resident #57 feeding pump and disconnected Resident #57's J-tube/G-tube [jejunostomy/gastrojejunostomy tube] from feeding. Staff B proceeded to flush Resident #57's J-tube with water. Staff B without donning a gown emptied Resident #57's J/G - tube drainage bag. Resident #57 physician order dated 3/4/2025 it read, Enhanced Barrier Precautions during high-contact resident activities: (dressing, bathing/showering, transferring, providing hygiene, changing linens, incontinent care or assisting with toileting, medical device care, wound care) every shift for indwelling medical devices. Resident #57 physician order dated 3/4/2025 read, G-tube port of G/J tube connected to continuous drainage system. Empty drainage bag QS [every shift] and prn [as needed] every shift for Duodenal Adenocarcinoma. During an interview on 3/12/2025 at 12:04 PM Staff B, LPN, stated, I should have had a gown on but there were none in the room. During an interview on 3/13/2025 at 9:12 AM the Director of Nursing (DON) stated, The staff should wear a gown and gloves when they are preforming high touch activities. They have to wear a gown and gloves. During an interview on 3/13/2024 at 9:19 AM Staff C, Infection Preventionist LPN, stated, Staff are supposed to wear a gown and gloves when coming into contact with a gastric tube or emptying a drainage bag. Review of facility policy and procedure titled Enhanced Barrier Precautions with a last review date of 12/16/2024 read, Policy: It is the policy of this facility to implement enhanced barrier precaution for the prevention of transmission of multidrug -resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines: 2. Initiation of Enhanced Barrier Precautions: .b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) .

Based on observation, interview, and record review the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principle for 1 of 1 resident receiving intravenous therapy, Resident #41 and 1 of 3 hallways reviewed for unattended medication. Findings include: 1) During an observation on 3/10/2025 at 9:46 AM, Resident #9 was sitting in his room. On top of his bedside table there was a clear medication cup containing a white circular pill. During an interview on 3/10/2025 at 9:46 AM with Resident #9 stated, I do not know why a nurse would leave a pill on the table. I do not have any idea at what hour it was given. This should be restricted; this is no way to give a medication. It has never happened before, but I was shocked to see it on my table. Review of Resident #9 physician orders did not show documentation of medication self-administration orders. During an observation on 3/10/2025 at 10:36 AM, Resident #42's room was empty. There was a medication cup with a white powdered substance on top of the drawer. During an observation on 3/10/2025 at 11:05 AM Resident #42 was sitting in his wheelchair in his room. There was a medication cup with a white powdered substance on top of the drawer. During an interview on 3/10/2025 at 11:05 AM Resident #42 stated, The nurses will apply the powder to the chaffing in my groin area. Review of Resident #42's physician orders did not show documentation of medication self-administration orders. During an interview on 3/13/2025 at 9:08 AM the Director of Nursing (DON), stated, We do an assessment and let the doctor know. We will do a self-administration assessment. Medication should not be left unattended in the room if they do not have a self-administration assessment. If they were able to self-administer the bedside dresser has a lock drawer and a key is provided. [Resident #9's name] or [Resident #42's name] do not have a self-administration assessment evaluations or self-administration orders. Review of the facility policy and procedure titled Medication Storage with a last review date of 12/16/2024 read, Policy: It is the policy of the facility to ensure all medications housed on our premises will be stored in the pharmacy, medication rooms, and/or on medication carts according to the manufacturer's recommendations, ensuring proper sanitation, temperature, light, ventilation, moisture control, segregation and security. Procedures: 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments under proper temperature controls. b. only authorized personnel or resident approved for self administration of drugs will have access to the keys to locked compartments. 51447 2) During an observation on 3/10/2025 at 10:23 AM, Resident #41 had intravenous fluids (IV) running into a catheter on his upper right arm. The fluid bag was labeled by the manufacturer as 0.9% Sodium Chloride. The rate on the medication pump was 100 milliliters per hour (ml/hr). Resident #41's catheter dressing on his right upper arm was dated 3/9/2025. There was no label on the IV tubing and there was no label on the fluids indicating when the bag and tubing were hung. During an observation on 3/11/2025 at 9:04 AM, Resident #41 had 0.9% Sodium Chloride running at a rate of 100 ml/hr. The bag of fluids did not have a date or time when it was hung by the nurse. The tubing was labeled 3/11/2025, 8:00 AM. During an interview on 3/13/2025 at 11:57 AM, Staff B, Licensed Practical Nurse (LPN) stated, When hanging IV tubing and fluids, they are to be labeled with date and time that they were hung. During an interview on 3/13/2025 at 12:30 PM, the Director of Nursing (DON), stated, Tubing and fluids should be labeled and dated with the date and time when they are administered. Review of Resident #41's physician order dated 1/24/2025 showed that Resident #41 is ordered to have Sodium Chloride Intravenous solution 0.9% with instructions reading, Use 1 liter of fluid intravenously one time a day every Monday, Tuesday for AKI (acute kidney injury) run at 100 ml/hr. Review of the facility's policy and procedure titled IV administration set (tubing) change last reviewed on 12/16/2024 showed it read, Explanation and Implementation Guidelines . Label the administration set and solution container with the date of initiation, as directed by your facility.

Based on interview and record review the facility failed to provide dialysis services consistent with professional standards related to the assessment of the resident's condition and monitoring for 1 of 2 residents reviewed for dialysis, Resident #57. Findings include: Review of Resident #57's physician order dated 2/11/2025 read, Pre/Post Dialysis Evaluation Assessment after resident returns from dialysis. Review of Resident #57's physician order dated 3/4/2025 read, Pre/Post Dialysis Evaluation Assessment after resident returns from dialysis every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday] for Dialysis. Review of Resident #57's assessments did not contain documentation of pre or post dialysis assessments on the following dates 2/19/2025 no pre-dialysis assessment, on 2/21/2025 no post dialysis assessment, on 2/26/2025 no post dialysis assessment, on 2/28/2025 no pre or post dialysis assessment, and on 3/7/2025 no post dialysis assessment. During an interview on 3/31/2025 at 2:40 PM with the Director of Nursing (DON) stated, We put in the order to tell staff what needs to be done. We want them to check on the resident when they get back from dialysis. Staff is expected to follow the order and do a pre and post dialysis assessment for [Resident #57's name]. Review of the facility policy and procedure tiled Dialysis Resident with a last review date of 12/16/2024 read, Policy: Care of the dialysis resident will be coordinated with the dialysis center.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during intravenous medication administration. Findings include: During an observation of medication administration on 11/27/2023 at 10:45 AM, Staff C, Licensed Practical Nurse (LPN), prepared medications for Resident #167 without performing hand hygiene, entered the resident's room and administered the medications. Staff C exited the room and went to the medication cart to prepare medications for another resident. During an observation of medication administration on 11/27/2023 at 11:00 AM, Staff C, LPN, prepared medications for Resident #52 without performing hand hygiene, entered the resident's room and administered the oral medications without performing hand hygiene. Staff C donned gloves and placed gloved hands inside the rim of the trash can and moved the trash can closer. Staff C then picked up the bag of antibiotics and intravenous tubing, removed the end cap of the intravenous tubing and attached the antibiotic bag to the intravenous line. Staff C held the uncapped end of the intravenous tubing in her left hand and cleansed the hub of the midline catheter with alcohol with right hand for less than 2 seconds. The uncapped end of the intravenous tubing was touching the sheets on the bed and the resident's arm. Staff C attached the intravenous tubing to the midline catheter, removed gloves, and exited the room without performing hand hygiene. During an interview conducted on 11/27/2023 at 11:07 AM, Staff C, LPN, stated, I did not wash my hands before preparing the medications. I reached into the trash can with my gloved hands. I should have changed my gloves after that. I didn't realize that the end of the IV line touched the resident or the sheets. During an interview on 11/29/2023 at 1:00 PM, the Director of Nursing (DON) stated, All staff should practice infection control standards and wash their hands before and after administering medications. Review of the facility policy and procedures titled Medication Administration with the last revision date of 2/27/2023 reads, Policy: Medications are administered by licensed nurses, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines . 4. Wash hands prior to administering medication per facility protocol and product. Review of the facility policy and procedures titled Hand Hygiene with the approval date of 1/30/2023 reads, Purpose: To ensure that all staff perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.

Based on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional standards and included expirations dates when applicable in 2 of 4 medication carts reviewed. Findings include: During an observation of Medication Cart 1 on 11/27/2023 at 9:15 AM with Staff A, Licensed Practical Nurse (LPN), there were one 30-milliliter medication cup with chocolate pudding and crushed pieces of medications with no label identifying the medication or any resident identifier, one opened bottle of Brimonidine/ timolol ophthalmic solution with no opened or expiration dates, and one opened Basaglar insulin pen with no opened or expiration dates. During an interview on 11/27/2023 at 9:25 AM, Staff A, LPN, stated, That cup of medications with the pudding is for a resident who refused the medications earlier and I was going to go back and check before I threw it out. I should have labeled who it was for and what medications were in it. The eye drops and insulin should have a date they were opened. During an observation of Medication Cart 2 on 11/27/2023 at 9:30 AM with Staff B, LPN, there were one 30-milliliter medication cup with chocolate pudding with pieces of crushed medications with no label identifying the medications or any resident identifier, one medication cup that contained two medications (one red capsule and one white tablet) with no label identifying the medications and no resident identifier, one medication cup with three medications (2 white tablets and 1 yellow tablet) with no label identifying the medications and no resident identifier, one medication cup with four tablets brown in color with no label identifying the medication and no resident identifier, one opened bottle of Polymycin B and trimethoprim ophthalmic solution with no opened or expiration dates, one opened bottle of Brimonidine ophthalmic solution with no opened or expiration dates, one opened bottle of Systane eye drops with no opened or expiration dates, and one opened bottle of Bimatoprost ophthalmic solution with no opened or expiration dates. During an interview on 11/27/2023 at 9:40 AM, Staff B, LPN, stated, I was just called away to help a resident and didn't get to give these medicines. I should have given them. They should be labeled with what the medications are and who they are for. I didn't have Vitamin B Complex, so I borrowed these from another nurse. There is no label as what they are. All eye drops should be labeled with the date they are opened or when they expire. During an interview on 11/29/2023 at 1:00 PM, the Director of Nursing (DON) stated, The nurses should administer the medications when they get them ready. They should have gotten a new bottle of Vitamin B Complex and not borrowed from another cart and put them in her cart. All medications should have the date opened or expiration dates on them. Review of the facility policy and procedures dated 2/27/2023 reads, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moist control, segregation and security.

Based on observation, interview, and record review, the facility failed to ensure accepted professional standards of practice were followed for intravenous medication administration via midline catheter for 1 of 3 residents with midline catheters, Resident #52. Findings include: Review of Resident #52's admission record showed the resident was admitted on [DATE] with the diagnoses including sepsis, tubo-ovarian abscess (a pocket of pus due to infection of the ovary and fallopian tube), pelvic inflammatory disease, peritoneal abscess, chronic obstructive pulmonary disease, essential primary hypertension, hyperlipidemia, iron deficiency anemia, primary osteoarthritis, and presence of artificial hip joint. Review of Resident #52's physician orders dated 11/4/2023 reads, Piperacillin Sod-Tazobactam So Solution Reconstituted 3-0.375 GM (grams), Use 3.375 gm intravenously four times a day for sepsis w/o [without] acute organ dysfunction/tubo ovarian abscess until 12/07/2023 06:59 [6:59 AM], Administer every 6 hours at 10am, 4 pm, 10pm, 4 am. Review of Resident #52's physician order dated 11/4/2023 reads, Flush midline using SASH method [Saline-ABT [Antibiotic]-Saline-Heparin) with each IV [Intravenous] ABT administration, four times a day for IV ABT. During an observation of medication administration on 11/27/2023 at 11:00 AM, Staff C, Licensed Practical Nurse (LPN), assembled all supplies for intravenous antibiotic administration for Resident # 52 without performing hand hygiene. Staff C, LPN, removed the end cap of the intravenous tubing and attached the antibiotic bag to the intravenous line. Staff C removed the end cap of the intravenous tubing and attached the antibiotic bag to the intravenous line. Staff C held the uncapped end of the intravenous tubing in her left hand and cleansed the needleless hub of the midline catheter with alcohol with right hand for less than 2 seconds. Staff C did not allow the needleless hub to dry before attaching a 10-milliliter normal saline flush. Without observing the insertion site or attempting to verify for blood return, Staff C administered the normal saline and the antibiotic. During an interview on 11/27/2023 at 11:07 AM, Staff C, LPN, stated, I did not verify for blood return prior to hanging the medicine. I should have cleaned the needleless connector longer and let it dry before giving the flush or antibiotic. During an interview on 11/29/2023 at 1:00 PM, the Director of Nursing (DON) stated, Staff should attempt to verify midline placement and clean the needleless connector before giving antibiotics. They should follow our procedures. Review of the facility policy and procedures titled Intermittent infusion device flushing and locking with the last revision date of 8/21/2023 reads, Introduction: An intermittent infusion device consists of an IV catheter with a needleless connector attached. This device helps maintain venous access in a patient who receives IV medications or solutions intermittently or in a patient who might need medications should an emergency arise. An intermittent flush device requires flushing before each infusion to assess vascular access device function, after each infusion to prevent mixing of incompatible medications and solutions, and after blood sampling to clear the device of blood and debris . Hospital-acquired condition alert: Keep in mind that the Centers for Medicare and Medicaid Services considers vascular catheter-associated infection a hospital acquired condition because it can reasonably [be] prevented using a variety of best practices. Make sure to follow evidence-based infection prevention practices, such as performing hand hygiene, using sterile no-touch technique, and performing a vigorous mechanical scrub of needleless connectors to reduce the risk of vascular catheter-associated infections . Implementation . Assess the intermittent infusion device insertion site to ensure that it's free from signs of infection, infiltration, and phlebitis . Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad. Allow it to dry completely. While maintaining sterility of the syringe tip, attach a prefilled 10-ml [milliliter] syringe or a syringe designed to generate lower injection pressure containing preservative-free normal saline solution to the needleless connector. Unclamp the intermittent infusion device and aspirate slowly for a blood return that's the color and consistency of whole blood. Review of the facility policy and procedures titled Medication Administration with the last revision date of 2/27/2023 reads, Policy: Medications are administered by licensed nurses, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines . 4. Wash hands prior to administering medication per facility protocol and product.

Based on interview and record view, the facility failed to develop a person-centered care plan for 1 of 3 residents reviewed for respiratory services, Resident #43. Findings include: Review of Resident #43's physician order dated 10/17/2023 reads, Apply Oxygen @ [at] 2 liters via nasal cannula for SOB [shortness of breath] or sats <90% [saturation less than 90 percent]. Review of Resident #43's Weights and Vital Summary reads, 11/21/2023 00:56 [12:56 AM] 93% (Oxygen via Nasal Cannula) . 11/17/2023 16:01 [4:01 PM] 98% (Oxygen via Nasal Cannula) . 11/06/2023 19:45 [7:45 PM] 96% (Oxygen via Nasal Cannula) . 11/04/2023 23:30 [1:30 PM] 95% (Oxygen via Nasal Cannula). Review of Resident #43's Minimum Data Set, dated dated dated [DATE] showed the resident uses oxygen while a resident. Review of Resident #43's care plan did not reveal a focus for shortness of breath or oxygen therapy. During an interview on 11/29/2023 at 2:00 PM, the Director of Nursing stated, Our practice is to develop care plans based on residents' needs. [Resident #43's name] had a physician order and there is documentation that oxygen was administered. There should have been a focus in her care plan regarding oxygen, but I do not see one. Review of the facility policy and procedures titled Comprehensive Care Plans with the last review date of 1/30/2023 reads, Policy: It is this policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the possible development and transmission of communicable diseases and infections. The facility failed to ensure staff performed hand hygiene during wound dressing change for Resident #33, and during medication administration for Resident #31, in a total sample of 25 residents. Findings include: 1. During an observation on 6/8/2022 at 8:42 AM, Staff B, Licensed Practical Nurse (LPN), was preparing to administer the morning medications for Resident #31. Staff B entered Resident #31's room with his medications and a portable/ wrist blood pressure (BP) apparatus that was on top of her medication cart. Staff B did not sanitize the blood pressure apparatus before she entered the resident's room. Staff B immediately applied the BP apparatus on Resident #31's right wrist and obtained a blood pressure reading of 115/84. Staff B administered the scheduled medications, then exited the room at 8:51 AM. Staff B did not sanitize or disinfect the BP apparatus after use and placed the apparatus back on to the medication cart. During an interview with Staff B, LPN, on 6/9/2022 at 10:05 AM in the presence of the Director of Nursing (DON), when asked what the process was to care for equipment for multiple resident use, Staff B stated, Like a blood pressure cuff, we sanitize them before and after use with a sanitizer wipe, leave for 2 minutes to dry. I have sanitizer wipes in my medication cart. When asked why she failed to sanitize the Blood Pressure cuff, Staff B replied, I was so nervous. Review of the facility policy and procedures titled Cleaning and Disinfection of Residents-Care Equipment reviewed on 1/25/2022, reads, Policy: Resident -Care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC [Centers for Disease Control and Prevention] recommendations in order to break the chain of infection . Policy Explanation and Compliance Guidelines: 1. Staff shall follow established infection control principles for cleaning and disinfecting reusable equipment. General guidelines include: . d. Multiple-resident use equipment shall be cleaned and disinfected after each use. e. Most equipment may be cleaned/ disinfected in the areas in which the equipment is used. 2. During an observation on 6/8/2022 at 11:25 AM, Staff C, LPN, accompanied with Staff D, Registered Nurse (RN), entered Resident #33's room to change wound dressing change. All wound dressing supplies were on a paper barrier over bedside table. Staff C washed her hands and donned a pair of gloves. Staff C exposed the resident's left foot, used a sanitized scissors to cut old dressing dated 6/6/2022. The left heel had an open wound approximately 10 centimeter in diameter. The wound was macerated, no drainage, surrounding tissue was pink. Staff C replaced gloves and washed hands in sink. Staff C cleansed the wound with normal saline. Staff C did not replace the gloves after cleansing the wound. Staff C immediately applied a dime size [MEDICATION(S)] on the wound, then applied [MEDICATION(S)] in a 4 x 4 gauze, used a Kerlix roll and wrapped the left heel. Staff C dated the dressing. During an interview with Staff D, RN, on 6/9/2022 at 10:40 AM, confirmed that Staff C failed to wash her hands and change gloves before applying the ointment ([MEDICATION(S)]). Staff D stated, She was very nervous. Review of the facility policy and procedures titled Wound Treatment with a revision date of 1/25/2022 reads, Policy: The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Review of the facility's Hand Hygiene Table showed hand hygiene with either soap and water or alcohol based hand rub before applying and after removing personal protective equipment (PPE), including gloves; before and after handling clean or soiled dressings, linen, etc.; and after handling items potentially contaminated with blood, body fluids, secretions, or excretions.

Based on observation, interview, and record review, the facility failed to ensure the services provided for gastrojejunostomy tube care met professional standards of quality to 1 of 5 residents with gastrostomy tube, Resident #26, in a total sample of 25 residents. Findings include: During an observation on 6/7/2022 beginning at 9:50 AM, Staff A, Licensed Practical Nurse (LPN), entered Resident #26's room. Staff A explained that she would be giving his morning medications through his gastrojejunostomy tube (GJ tube). Staff A sanitized her hands and prepared to pull the resident's medications from the medication cart. Staff A placed the medications into the individual medication cup. Staff A crushed all the pills individually. Staff A entered the resident's room and placed all medications on a bedside table. Staff A donned a pair of gloves and opened a new feeding syringe. Staff A checked the resident's identification. Staff A exposed the resident's abdomen to visualize his GJ tube. Staff A immediately flushed the GJ tube with 15 milliliter (ml) water. Staff A did not check for tube placement, did not do visual check for tube placement, and did not check for gastric residual prior to flushing the GJ tube with 15 ml water. Staff A proceeded to administer all the medications separately with 10 ml of water. Staff A flushed the GJ tube after each medication administration. Staff A made a final flush with 60 ml of water. Staff A cleaned the bedside table, washed her hands in the bathroom sink, then exited the resident's room at 10:12 AM. During an interview with Staff A, LPN, on 6/7/2022 at 10:13 AM, when asked why she did not check for tube placement, Staff A stated, Our DON [Director of Nursing] told us that we no longer need to check for tube placement. We only check for residuals. DON stated that we are injecting too much air to the tube. Sorry, I forgot to check for residual. During an interview with the DON on 6/7/2022 at 3:10 PM, when asked what the policy on medication administration via GJ tube is, the DON stated, The latest best practice in literature is that we do not put in air any longer, but nurse is supposed to check for residual, do visual check of the tube for placement, and if suspicious, we get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility policy and procedure titled Medication Administration via Enteral Tube with a revision date of 1/25/2022 reads, Policy: It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines . 9. Procedure: . h. Check that tube is in place. Check external tube and if suspected of dislodgement, notify doctor to get x/ray. I. Check residual per physicians' order.

Based on observation, interview, and policy and procedure review, the facility failed to properly store food designated for resident usage in the freezer of the rehabilitation wing kitchen, which is utilized by 20 residents. On 12/29/20 at 02:17 PM, during a tour of the rehabilitation wing kitchen conducted with Staff E, Dietary Cook observed was an opened five-quart container of lemon sorbet. The lemon sorbet was not labeled with an open date or a discard date. There was an opened unsealed container of blueberry muffins which was not labeled with an open date. (Photographic evidence). During an interview on 12/29/20 at 02:19 PM with Staff E, Dietary Cook he confirmed in the freezer the lemon sorbet was opened, was not labeled or dated when it was opened. He confirmed the frozen blueberry muffins in the freezer in the rehabilitation kitchen were opened, not sealed, not labeled or dated with the open date. A review of the facility's policy and procedure titled, Date Marking for Food Safety, revised on 10/24/2020 reads in part, Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for food safety. Policy explanation and compliance guidelines. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a color-coded label, the day/date the item must be consumed or discarded.

Based on observation, interview, and policy and procedure review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and to include the expiration date when applicable for 4 of 4 medication carts and 1 of 2 medication storage rooms. Findings: During an observation of medication cart #1 on [DATE] at 8:55 AM with Staff A, LPN (Licensed Practical Nurse) there was a medication cup that contained four white pills and one orange pill. The medication cup was not labeled with a resident identifier or the medications contained in the medication cup. There was a medication cup that contained three yellow tablets. The medication cup was not labeled with a resident identifier or the medications contained in the medication cup. During an interview on [DATE] at 9:00 AM with Staff A, LPN she stated, I should not have unlabeled medications on the cart. The resident was not in the room and I shouldn't have poured the medications before I knew that the resident was available. I'm not sure what those medicines are, I can't remember. The three pills in the medicine cup were not put there by me. I'm not sure what they are. We should not have unlabeled or unidentified medicines in the medication cart. During an observation on [DATE] at 9:09 AM of medication cart #2 with Staff B, LPN it showed there was a bottle of [MEDICATION NAME] 0.01% eye drops that was not labeled with an open date or an expiration date for Resident #45. During an interview with Staff B, LPN on [DATE] at 9:15 AM she stated, Eye drops should be labeled with the date opened and the expiration date. These [MEDICATION NAME] eye drops don't have those. During an observation of medication cart #3 on [DATE] at 9:17 AM with Staff C, LPN it showed there was one bottle of [MEDICATION NAME] 1% eye drops with a date opened of [DATE] with no resident identifier and one bottle of Gas relief tablets with an expiration date of ,[DATE]. During an interview with Staff C, LPN she stated, Those eye drops are expired. I'm not sure why they are still on the cart. Medications that have a date of the month and a year they expire; those medications expire on the last day of that month, so the gas relief tablets expired on [DATE]. During an observation on [DATE] at 9:40 AM of medication cart #4 with Staff D, LPN it showed there was one bottle of Muro 128 eye drops for Resident #48 with an open date of [DATE], and no expiration date. During an interview with Staff D, LPN on [DATE] at 9:50 AM she stated, Eye drops expire 30 days after they are opened. During an observation of medication storage room [ROOM NUMBER] on [DATE] at 9:59 AM with Staff B, LPN it showed there was one [MEDICATION NAME] ([MEDICATION NAME] purified protein derivative; used as an aid in the detection of infection with [DIAGNOSES REDACTED]) syringe for Resident #42 with an expiration date of [DATE]. During an interview on [DATE] at 10:01 AM with Staff B, LPN she stated, That is expired. It should not be left in the refrigerator. During an interview with the Director of Nursing on [DATE] at 3:30 PM she stated, We should not have unlabeled medications on the medication carts. No nurses should pre pour medications without checking and making sure the resident is available to take them. All medications should be labeled with the resident's name, the date it was opened and when the medication expires. Review of the policy and procedure titled, Labeling of Medications and Biologicals, with an approval date of [DATE] reads: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. 1. All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices. 4. Labels for individual drug containers must include: a. The resident's name. h. The expiration date when applicable.

Based on observation, interview, and record review, the facility failed to ensure respiratory care services were provided in accordance with professional standards of practice for 1 of 2 residents sampled for respiratory care, Resident #20, in a total sample of 15 residents. Findings: Review of Resident #20's facility medical record revealed the resident has [DIAGNOSES REDACTED]. Review of the physician order dated 5/27/2020 reads: Oxygen 2 liters via nasal cannula every shift for shortness of breath. During an observation of Resident #20 on 12/28/2020 at 12:02 PM it showed oxygen was being administered at 3 liters via nasal cannula. During an observation of Resident #20 on 12/28/2020 at 3:25 PM oxygen was being administered at 3 liters via nasal cannula. During an observation of Resident #20 on 12/29/2020 at 7:45 AM oxygen was being administered at 3 liters via nasal cannula. During an observation of Resident #20 on 12/29/2020 at 1:15 PM oxygen was being administered at 3 liters via nasal cannula. During an observation of Resident #20 on 12/29/2020 at 2:15 PM with the Director of Nursing (DON), the DON verified the resident was being administered oxygen via nasal cannula at 3 liters per the setting on the oxygen concentrator. Review of Care plan for Resident #20 dated 10/20/2020 read: Respiratory needs: My respiratory needs will be met. I will receive O2 (oxygen) at 2 liters by nasal cannula. During an interview with the Director of Nursing on 12/30/2020 at 12:02 PM she stated, He is on hospice and we have had times when we have increased his oxygen to maintain his oxygen saturation. We should be checking the oxygen concentrators to verify the amount of oxygen a patient is on when they come on shift. It is part of an assessment of the resident. If we need to increase the oxygen, we should be letting the doctor know and writing an order to increase the oxygen. I expect our staff to follow physician orders and to check to make sure they are on the correct amount. Review of the facility policy and procedure titled, Physician Orders, with an approval date of 10/15/2020 reads: It is the policy of this facility to ensure staff is following physician orders to meet current standards of practice. 5. The nurse will follow the instruction of the order.

Based on interview, observation, and policy and procedure review the facility failed to ensure expired medications and treatments were removed from active use medications and treatments. Findings: On 10/8/2019 at 08:20 AM an observation of the facilities medication storage room off the 1700 hallway with Staff A, LPN (Licensed practical nurse) revealed five syringes of clear fluid labeled [MEDICATION NAME] 50 united states pharmacopoeia (USP) in 5 mL (milliliters) with expiration dates of 05/2019. An observation of the medication room on the 1900 hallway with Staff C, Wound Care LPN, revealed a tube of [MEDICATION NAME] hydrogel wound dressing with Vitamin [NAME] with an expired date of 03/2019. On 10/08/2019 at 08:40 AM an observation and interview was conducted with Staff A, LPN. He confirmed the five syringes of clear fluid labeled [MEDICATION NAME] 50 USP in 5 mL with expiration dates of 05/2019. He stated, These medications should not be included in the main medication room inventory to be used for a residents. On 10/08/2019 at 08:40 AM an interview and observation was conducted with Staff C, LPN/Wound Care Nurse in the 1900 hallway medication storage room. She confirmed the tube of expired [MEDICATION NAME] hydrogel wound dressing with Vitamin [NAME] had expired on 03/2019 and should not be in the treatment cart to be used on a resident. On 10/08/2019 at 4:46 PM an interview was conducted with Staff K, Central Supply Clerk. When asked about the expired medications found in the medication rooms she stated, Once a month and as needed I go into the medication room and mark on my medication inventory sheet what is low. When something is expired I notify the quality assurance nurse. Review of the Medication Inventory sheet For (MONTH) 2019, showed we did not find any expired medications. On 10/08/2019 at 08:45 AM an interview was conducted with the Director of Nursing (DON). The DON confirmed the expired medications should not be in the medications or treatment room inventory that could be used on a resident. The DON confirmed by observation in the main medication storage room, the five syringes of [MEDICATION NAME] 50 USP in 5 mL had expired on 05/2019. Review of the facilities policy titled: Storage of Medications; Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview and record review the facility failed to ensure residents received treatment and care for 1 of 2 residents, Resident #12 in a total sample of 29 residents. Findings: Review of Resident #12's record revealed a physician's orders [REDACTED].= For pain. An observation of Resident #12 was conducted on 10/07/19 at 10:42 AM and showed Resident #12 was observed with both her left and right legs propped on top of a pillow. There were no foam boots/heal protectors observed. An observation of Resident #12 was conducted on 10/8/19 at 10:30 AM and showed there were no foam boots/heel protectors observed on the resident's lower extremities. An observation of Resident #12 was conducted on 10/9/19 at 09:23 AM and showed there were no foam boots/heel protectors observed on the resident's lower extremities. On 10/9/19 at 09:23 AM an interview with Resident #12 was conducted and she stated, I have never worn any foam boots. I always have pain in my heels. On 10/09/19 at 12:06 PM, during an interview Staff J, Licensed Practical Nurse (LPN) confirmed the resident is supposed to wear foam boots to help with the pain in her heels. Staff J confirmed she signed off on Resident #12's Treatment Administration Record on 10/8/19 that resident #12's bilateral heel boots were administered and that she did not put the boots on the resident all day. On 10/9/19 at 10:50 AM an interview with the Director of Nursing was conducted she confirmed that Resident #12 should be wearing bilateral boots for pain according to physician's orders [REDACTED].

Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good personal hygiene for 1 resident, Resident #39 out of 3 sampled for ADLs in a total of 29 sampled residents. Findings: On 10/7/2019 at 10:40 AM an observation was conducted of Resident #39. She was observed sitting up in bed with her legs and feet exposed. During an interview on 10/7/2019 at 10:40 AM with Resident #39 when asked about her toenails she stated, Yes they are very long and no one will cut them. On 10/8/10 at 1:00 PM an observation with Staff B, LPN (Licensed Practical Nurse) was conducted for Resident #39. Staff B, LPN confirmed the resident had very long toenails. The Resident stated, I had my bath today, I needed my toenails cut. Staff B, LPN stated, No one told me her toenails were this long. The second nail on the right foot is even curling over her toe. On 10/8/19 at 1:15 PM an interview was conducted with Staff D, CNA (Certified Nursing Assistant). She confirmed she was on shower duty and showed a shower sheet for Resident #39. Nothing was documented on the shower sheet for Resident #39's long toenails. Staff D, CNA was asked who cuts residents nails she stated, When the shower team give a resident a shower or anytime a Certified Nursing Assistant (CNA) sees a resident's toenails are too long we report it to the nurse and write it on the shower sheet. CNAs do not cut toenails only fingernails. On 10/8/19 at 1:05 PM an interview was conducted with Staff A, LPN. He stated that the CNA's are supposed to tell the nurse when they notice the resident has any skin changes or their toenails are too long so that we can cut them or have them seen by the Podiatrist if they are diabetic. On 10/08/19 at 2:45 PM an interview with the Director of Nursing (DON) was conducted. When asked about the facilities policy and protocol for resident's toenails specifically for residents who need assistance with grooming, she stated, Typically the nails are checked as part of the skin check during the resident's shower/bath. The CNA fills out a shower sheet on each resident noting any areas of concerns, this includes fingernails and toenails. This alerts the nurse to any areas of concerns that need to be taken care of. Review of Shower sheet for Resident #39 dated 10/08/2019 showed: Staff B, LPN signature and Staff D, CNA signature. Follow up action by nurse was blank. No notation was on the shower sheet about the resident's very long toenails. Review of the Minimal Data Sheet. Section G ADL (Activities of Daily Living) Functional Status. Self Performance for Personal hygiene: 3-Extensive assistance and Support; 2-one person assist. Review of the Resident's care plan showed: (P) I require limited or extensive assistance with my bathing, grooming, dressing, mobility and eating. Related to decreased mobility and weakness. (G) I prefer to remain clean, neat, dressed appropriately for the season and free of body odor. (A). Nail Care (A). Please assist me with applying moisturizing lotion to my feet and toes after bathing. Review of Policy titled: Nail Care Policy for Oak Hammock. Policy; To provide appropriate nail grooming and nail hygiene. Procedure: 1. All residents to be assessed for nail care upon admission, weekly skin checks and shower sheets. 2. Nail care is to be provided by nursing staff unless other wise indicated. 3. Nail care to include: a) cutting, trimming and filing nails.